Friday, December 18, 2015

A study found that adults with autism are
at higher risk for a number of health problems,
ranging from diabetes and obesity to heart failure. In a review of insurance
records for more than 23,000 adults, researchers found that medical and
psychiatric issues are much more prevalent in those with autism as compared to
individuals without the neurodevelopmental disorder. Nearly all medical
conditions were significantly more common in adults with autism than controls,
including diabetes, gastrointestinal (GI) disorders, epilepsy, sleep disorders,
dyslipidemia, hypertension and obesity, researchers reported in a summary of
their findings presented at the International Meeting for Autism Research.

Eating disorders,
mechanical falls, vision and hearing impairments, osteoporosis and chronic
heart failure were significantly more common among adults with autism than
controls. Depression and anxiety were more than twice as common for those on
the spectrum while bipolar disorder was eight times as likely. There was also
12-fold increase in the risk of epilepsy for this group. Nearly a third of
those with autism in the study had obesity or hypertension, conditions that
affected less than 20 percent of those without the neurodevelopmental disorder.
Cancer rates, however, were similar for those with and without autism.

Although it’s well-known
that children with autism face more medical and psychiatric diagnoses than
their peers, this is the first large study to examine how common these issues
are in adults. Researchers suggest that one reason for the high prevalence of
health problems among adults with autism could be that the social and
communication difficulties as well as the sensory sensitivities common among
this population may lead to reduced preventive care. They conclude that
physicians need better training on how to treat individuals on the spectrum
throughout the life span and improvements needed in the transition from
pediatric to adult medical care systems.

Sunday, November 1, 2015

The Individuals with
Disabilities Education Improvement Act of 2004 (IDEA) (P.L. 108-446) (http://idea.ed.gov/) guarantees a free and
appropriate public education (FAPE) in the least restrictive environment (LRE)
for every student with a disability. The LRE provision mandates that “to the
maximum extent appropriate, children with disabilities, including children in
public or private institutions or other care facilities, are educated with
children who are not disabled, and special classes, separate schooling, or
other removal of children with disabilities from the regular educational
environment occurs only when the nature or severity of the disability of a
child is such that education in regular classes with the use of supplementary
aids and services cannot be achieved satisfactorily.” In general,
inclusion (or inclusive education) with typical peers is considered to be
the best placement option for students with disabilities. It should also
be noted that while the least restrictive environment (LRE) provision of IDEA
requires that efforts be made to educate students with special needs in less
restrictive settings, IDEA also recognizes that some students may require a
more comprehensive program and intensive level of service.

Child characteristics such
as severity of autism symptoms are thought to determine educational placement.
However, where a child lives may significantly impact whether they are placed
in an inclusive or segregated classroom, a national analysis suggests. The
study published online in the journal Focus
on Autism and Other Developmental Disabilities examined external
factors, including state of residence and state funding formulas, to determine
their potential influence on placement outcomes. On
average, about 37 percent of students on the autism spectrum spent at least 80 percent
of their school day in inclusive environments. But the numbers varied
considerably from one state to the next, ranging from just 8 percent in
Washington, D.C. to 62 percent in Iowa. There was considerable variation among states in placing students with autism
spectrum disorder (ASD) in inclusive, mainstreaming, self-contained, and
separate schools. Specifically, states varied substantially in the percentage of
students with ASD educated in each setting, with some states consistently favoring inclusion (Colorado, Connecticut, Idaho, Iowa,
Minnesota, Nebraska, North Dakota, West Virginia, and Wisconsin). Other states,
however, generally leaned toward more restrictive settings (Alaska, Delaware,
Florida, Hawaii, Louisiana, New Hampshire, New Jersey, New York, South Carolina,
and Washington, D.C.). States in the Eastern United States tended to
have more restrictive placement rates than states in the Western United States.
State special education funding was found to have a minimal impact on placement
outcomes.

These findings suggest
that factors that are external to child characteristics (e.g., severity of ASD
symptoms) influence educational placement decisions for students with ASD. “If
child-specific factors were solely responsible for education placement decisions,
one would expect states to have similar rates of inclusive, self-contained,
mainstreaming and separate school placements for students with ASDs,” the
author commented. “Instead, … results indicate that educational placement
varies by state.”

Overall, it is
unlikely that child characteristics alone determine placement outcomes.
Although School districts should make every effort to place students in
integrated settings to maximize interaction with typical peers, analysis
of the public data presented in this study suggests that many states are still
falling short of including students with ASD in general education settings for
significant portions of the day. Inclusion with typically developing students
is important for a child with ASD as peers provide the best models for language
and social skills. However, inclusive education alone is insufficient,
evidence-based intervention and training is also necessary to address specific
skill deficits. The argument must shift from should we include autistic students in general education to understanding how to include them successfully. It is critical to identify
how practices that benefit students with ASD, including structure
(visual, communication, and social supports), positive behavior supports, and
systematic instruction, can be implemented effectively in general education
settings.

Saturday, October 31, 2015

More children than ever before are being
diagnosed with autism spectrum disorder (ASD). The dramatic increase in the
prevalence of children with ASD has created an urgent need
for effective and efficient service delivery models. Parents and caregivers
everywhere are eager for credible, research-based information on the most
effective treatments for ASD. Utilizing a group training format, researchers
have found that parents can learn to successfully incorporate an established
treatment for ASD into everyday interactions with their children. According to
findings published in theJournal
of Child Psychology and Psychiatry, parents learned to successfully
apply an evidence-based therapy method calledPivotal Response
Treatment (PRT), also referred to as Pivotal Response Training, and
observed meaningful improvement in their children.

PRTis one of the best studied and
validated behavioral treatments for autism. It is a naturalistic behavioral
intervention derived from the principles of Applied Behavior Analysis (ABA).PRTbuilds on learner initiative and
interests, and is particularly effective for developing communication,
language, play, and social behaviors. PRT was developed to create a more
efficient and effective intervention by enhancing four pivotal learning
variables: motivation, responding to multiple cues, self-management, and
self-initiations. According to theory, these skills are pivotal because they
are the foundational skills upon which learners with ASD can make widespread
and generalized improvements in many other areas.

The objective of the study was to evaluate a
PRT parent training group (PRTG) for targeting language deficits in young
children with ASD. For the study, researchers randomly assigned parents of 53
children with autism to participate in 12 weeks of classes on PRT or a
psychoeducation group (PEG). All of the children were between the ages of 2 and
6 and had language delays. The PRTG taught parents behavioral techniques to
facilitate language development. The PEG taught general information about ASD.
All of the children were assessed at the outset of the study, at six weeks and
at 12 weeks to determine their language abilities. Parents were also videotaped
at six and 12 weeks to measure how well they were applying the treatment.

The results indicated that parents were able
to learn PRT in a group format, as the majority of parents in the PRTG (84%)
were using it correctly by the end of the study. Children also demonstrated
improvement in adaptive communication skills. Children whose parents learned
the technique reported greater gains in both the number of words used and how
they used them as compared to children in the psychoeducation (control) group.

This study is considered the first randomized
controlled test of group-delivered PRT and one of the largest experimental
investigations of the PRT model to date. The findings suggest that specific
instruction in PRT results in greater skill acquisition for both parents and
children, especially in functional and adaptive communication skills. Even with
the improvements, researchers said that parent-implemented approaches are
intended to augment, not replace, autism therapies from professionals. Likewise,
further research in PRT is warranted to replicate the observed results and
address other core ASD symptoms. It should also be noted that research findings
are not the only factor involved when selecting an intervention. Professional
judgment and the values and preferences of parents, caregivers, and the
individual are also important.

Tuesday, October 27, 2015

Younger siblings of
children with autism spectrum disorder (ASD) are at high risk for developing
ASD as well as features of the broader autism phenotype. About 20% of younger
siblings of children with Autism Spectrum Disorder (ASD) will develop the
condition by age 3. Astudy
by Yale School of Medicine researchers has found that 57% of these younger
siblings who later develop the condition already showed warning signs like poor
eye contact and repetitive behaviors at just a year and a half old. Published
in the Journal
of the American Academy of Child & Adolescent Psychiatry, this is
the first large-scale, multi-site study aimed at identifying specific
social-communicative behaviors that distinguish infants with ASD from their
typically and atypically developing high-risk peers as early as 18 months of
age. For the study, researchers looked at data on 719 infants who had older
siblings on the spectrum. The children were assessed at 18 months and again at
36 months to identify social, communication and repetitive behaviors that could
be predictive of autism.

Three distinct
combinations of features at 18 months were predictive of ASD outcome: 1) poor
eye contact combined with lack of communicative gestures and giving; 2) poor
eye contact combined with a lack of imaginative play; and 3) lack of giving and
presence of repetitive behaviors, but with intact eye contact. These 18-month
behavioral profiles predicted ASD versus non-ASD status at 36 months with 82.7%
accuracy in an initial test sample and 77.3% accuracy in a validation sample.
Clinical features at age 3 among children with ASD varied as a function of
their 18-month symptom profiles. Children with ASD who were misclassified at 18
months were higher functioning, and their autism symptoms increased between 18
and 36 months.

"While the majority
of siblings of children with ASD will not develop the condition themselves, for
those who do, one of the key priorities is finding more effective ways of
identifying and treating them as early as possible," said lead author
Katarzyna Chawarska, associate professor in the Yale Child Study Center and the
Department of Pediatrics at Yale School of Medicine. "Our study reinforces
the need for repeated diagnostic screening in the first three years of life to
identify individual cases of ASD as soon as behavioral symptoms are
apparent." Early detection, especially when toddlers have siblings with
autism, is critical. Chawarska added, "Linking these developmental
dynamics with underlying neurobiology may advance our understanding of causes
of ASD and further efforts to personalize treatment for ASD by tailoring it to
specific clinical profiles and their developmental dynamics."

“18-Month Predictors of
Later Outcomes in Younger Siblings of Children With Autism Spectrum Disorder: A
Baby Siblings Research Consortium Study.” Published online 06 October
2014. Journal
of the American Academy of Child & Adolescent Psychiatry.

Thursday, October 1, 2015

The increase in
the prevalence of autism spectrum conditions among children and adolescents and
the correspondingly large number of youth transitioning into adulthood has
created an urgent need to address the mental health needs, isolation, and poor quality of life faced by many adults on the
autism spectrum. Unfortunately, there are few validated treatment options are
available for adults with autism spectrum disorder (ASD). Much of the published
literature is clinical or anecdotal, or purely based on theory. There is unquestionably
a need for the development of treatment options for adults with ASD. At
present, alternative treatment options to psycho-therapeutical interventions
are social training programs and other group activities. Group settings enable
social interaction and sharing experiences with others, thereby reducing social
isolation.

Research

A study published in the peer reviewed journal Autism assessed the
effectiveness of two group interventions for adults with ASD: cognitive behavioral
therapy (CBT) and recreational activity.A
total of 68 adults with ASD participated in the study and were stratified by
gender and blindly randomized to one of the two treatment conditions. Both interventions comprised 36 weekly 3-hour sessions led by two therapists in groups of 6–8 participants. The CBT
group intervention was adapted to suit adults with ASD and consisted of five
elements: (a) structure, (b) group setting, (c) psycho-education (e.g. lectures
and discussions on ASD and psychiatric symptoms, including learning to identify
and reappraise maladaptive thoughts), (d) social training (e.g. skill building
such as practicing phone calls and asking for help) and (e) cognitive behavioral
techniques (e.g. setting goals, role-playing, exposure exercises and conducting
behavior analysis). A manual describing the 36 individual sessions was created
prior to starting the treatment. Each session followed a strict agenda: (a)
introduction and presentation of the agenda of the day, (b) review of homework
assignments from the previous session, (c) psycho-educative lecture and
discussions on the session topic, (d) coffee break with buns or sandwiches and
social interaction, (e) relaxation or mindfulness exercise, (f) discussions and
exercises on the session topic, (g) distribution of homework and (h) evaluation
and end of session.

The purpose of the
recreational activity intervention was to facilitate social interaction and to
break social isolation. The therapists did not provide any deliberate
techniques, such as psycho-education, social training, or CBT. Rather, this
intervention relied on structure and group setting only. During the first
session, participants were asked to write down group activities they would like
to engage in. The therapists created a list of the suggested activities, such
as visiting museums, playing board games, cooking, restaurant visits, boating,
cinema, and taking walks. Each week, participants voted for the next session’s
activity.

The researchers
hypothesized that both interventions would lead to improvement in primary measures
of quality of life, sense of coherence, and self-esteem, as well as in the
exploratory analysis of the secondary measures of psychiatric symptoms. A
greater effect in the CBT intervention compared to recreational activity was
also expected, due to participants in the CBT intervention receiving a wider
range of psychotherapeutic techniques. Several self-report questionnaire measures
were administered to the adults before and after the interventions: Quality of
Life Inventory (health, relationships, employment, and living conditions),
Sense of Coherence (manageability and meaningfulness in life), Rosenberg Self
Esteem Scale and an exploratory analysis on measures of psychiatric health (e.g.,
anxiety and depression). A long-term follow-up was conducted which ranged from 8 to 57 months after treatment termination.

Results

Participants in both
treatment conditions reported an increased quality of life at post-treatment,
with no significant difference between the group CBT and group recreational activity
interventions. Comorbid psychiatric symptoms, sense of coherence, and
self-esteem were not affected by either intervention. CBT resulted in less
attrition (drop out) than recreational activity. Participants who received CBT also
rated themselves as more improved at post-treatment. At follow-up, CBT
participants reported better well-being, greater understanding of their own
difficulties and improved ability to express needs, compared to participants in
the recreational activity intervention. This may reflect the recreation
activity intervention’s focus on the intervention elements of structure and
group setting, while the CBT intervention also included the elements of
psycho-education, social training and CBT techniques. As a result, participants
in CBT may have developed greater understanding of their own difficulties and
improved ability to express needs and receive support because the objective of
psycho-education and social training is to enhance these capabilities. The difference
in well-being scores at follow-up may also represent greater insight gained
from CBT rather than recreational activity.

Implications

Both interventions appear
to be promising treatment options for adults with ASD, as they appeared to
improve the participants’ quality of life. The similar efficacy of the
interventions may be due to the common elements of structure and group setting.
The group setting of both interventions enabled social interaction and sharing
experiences. This may have promoted participants’ self-acceptance by allowing
them to gain insight into both the impairments and the strengths that
characterize ASD, and to recognize that others share similar challenges. CBT
may be additionally beneficial in terms of increasing specific skills, greater
understanding and insight, and minimizing dropout. Future studies on treatment
of comorbid psychiatric symptoms in ASD should include larger samples to
differentiate between adults with specific psychiatric problems in order to
more effectively assess treatment effects.

Tuesday, August 25, 2015

Autism is a disorder with
no known cause or cure. Parents of children with ASD will understandably pursue
interventions and treatments that offer the possibility of helping their child,
particularly if they are perceived as unlikely to have any adverse effects. Unfortunately,
families are often exposed to unsubstantiated, pseudoscientific theories, and
related clinical practices that are ineffective and compete with validated
treatments, or that have the potential to result in physical, emotional, or
financial harm. The time, effort, and financial resources spent on ineffective
treatments can create an additional burden on families. As a result, parents and caregivers everywhere are eager for credible, research-based information
on the most effective treatments for autism spectrum disorders (ASD). To
address this need, the National
Autism Center has published the manual, A Parent's Guide to Evidence-Based Practice and Autism, to help parents and caregivers differentiate empirically validated
treatment approaches from treatments that are unproven and/or potentially
ineffective.

The 134-page manual
focuses on helping parents as they make decisions about how to best help children
with ASD reach their full potential. It begins with a review of the autism
spectrum, symptoms, and co-occurring conditions, and identifies and describes
effective treatments. Other topics include the importance of professional
judgment, the role of family preferences and values in the decision-making
process, and factors to consider when choosing a team of professionals to help
their child.

“Finding information about
autism is easy. It is much more difficult to find reliable information that has
withstood the rigors of science, is comprehensive in scope, and is accessible
and easy to read,” said Hanna C.
Rue, Ph.D., BCBA-D, Director of Evidence-based Practice for the National Autism
Center and one of the manual’s authors. “Even for a trained professional,
sorting through the clutter to find information that is most relevant to a
child’s needs is a complicated and challenging process.”

One of the most
distinctive and important features of this manual is that it was co-authored by
professionals and parents of children with autism. “As professionals, we think
about treatment from an entirely different perspective than a parent,” Dr. Rue
comments. “We felt it was critical that the parent experience be reflected in
every aspect of the manual.”

The manual is the latest
in a series of publications by the National Autism Center. Visit the Center’s
website to download a free copy, watch a video, or learn more.

An advocate for
evidence-based treatment approaches, the National Autism Center identifies effective
programming and shares practical information with families about how to respond
to the challenges they face. The Center also conducts applied research and
develops training and service models for practitioners. Finally, the Center
works to shape public policy concerning ASD and its treatment through the
development and dissemination of National
Standards of Practice.

Wednesday, August 19, 2015

Young
adults with autism are facing significant challenges as they transition to
adulthood, a national report suggests, with
many on the spectrum finding themselves unemployed, isolated, and lacking
services. The "National Autism Indicators Report: Transition into Young
Adulthood" from Drexel University’s A.J. Drexel Autism Institute
is a comprehensive report (available free online) that presents new findings
about a wide range of experiences and outcomes of youth on the autism spectrum
between high school and their early 20s. The report is a collection of
indicators that focuses national attention on outcomes which are almost
universally lower for those on the autism spectrum compared to their peers with
other types of disabilities and serves as a call to action to fill the
remaining large gaps in knowledge. Key findings include:

Over one-third (37 percent) of young adults were disconnected during their early 20s, meaning they never got a
job or continued education after high school. In comparison, less than
eight percent of young adults with other types of disabilities were
disconnected.

Approximately 26 percent of young adults and
28 percent of those unemployed and not in school received no services
which could help them with employment, continue their education, or live
more independently.

Just 58 percent of young adults worked for pay
outside the home between high school and their early 20s, a rate far lower
than young adults with other types of disabilities. Those with jobs
generally worked part-time for relatively low wages.

Approximately one in four young adults were
socially isolated, meaning they never saw or talked with friends and were
never invited to social activities within the past year.

Only about one in five ended up living
independently (without parental supervision) in the period between high
school and their early 20s.

Sixty percent of youth had at least two health
or mental health conditions in addition to autism spectrum disorder. Over
half of youth had co-occurring ADD/ADHD and anxiety issues in adolescence.
Three-quarters of youth took at least one kind of medication on a regular
basis for any health or mental health issue.

Nearly 50% of youth experienced threats and
bullying during high school. Over one-quarter (27 percent) of adolescents
engaged in some type of wandering behavior in which they impulsively left
a supervised situation, increasing their risk of becoming lost and going
missing.

Transition Planning, a key process for helping
youth build skills and access services as they enter adulthood, was
frequently delayed. Just 58 percent of youth had a transition plan by the
federally required age.

The creation of effective
and affordable programming tailored to meet the needs of the 50,000 individuals
with autism who leave high school each year - each with unique strengths,
interests, and challenges - is an urgent task facing our society. It is clear
that we are not succeeding as a nation in helping autistic adults to thrive to
the best of their abilities and attain a high quality of life. It is time for
new approaches.

“This is the most
comprehensive report to date describing what we know about young adults with
autism as a whole and across the various parts of their lives. Yet, it
represents only a fraction of what we need to know. Huge gaps remain,” said
Anne M. Roux, MPH, research scientist at the A.J. Drexel Autism Institute in
the Life Course Outcomes Research Program and lead author of the report.
Although these indicators don’t tell us why outcomes are worse for those with
autism compared to youth with other disabilities, this report is an important
first step toward addressing the gaps in what we know, as we work to build an
evidence base about how to help achieve better outcomes.

Tuesday, August 11, 2015

Music therapy has become
an integral part of many programs for children with autism. The broad category
of music therapy is generally described as interventions that seek to teach
individual skills or goals through music. Music therapists use their training
as musicians, clinicians, and researchers to effect changes in cognitive,
physical, communication, social, and emotional skills. According to the National Autistic Society, “Music therapy
aims to encourage increased self-awareness/self-other awareness, leading to
more overt social interactions. The therapy stimulates and develops the
communicative use of voice and pre-verbal dialogue with another, establishing
meaning and relationship to underpin language development. The client may also
benefit from increased tolerance of sound, tolerance of and capacity for
two-way communication.”

Research
Autism reports strong positive evidence from peer-reviewed journals that
support the effectiveness of music therapy for individuals with autism spectrum
disorders (ASD). Based on the literature to date, music therapy has shown good
effects in influencing joint attention, social interaction, verbal and gestural
communication and behavior. It is considered to be a useful intervention,
particularly with young children, and where language acquisition is either
delayed or disordered to a severe degree. Currently, music therapy
is identified as an emerging intervention by the National Autism Center (2015)
and incorporates many of the identified ASD-specific evidence-based practices.Supporters of music therapy emphasize
that it can be used to develop social engagement, joint attention, communication
abilities, while also addressing emotional needs and quality of life.

A study published in the
journal Autism
provides further support for the effectiveness of music therapy with ASD. This
study investigated the social-motivational aspects of musical interaction
between the child and the therapist in improvisational music therapy by
measuring emotional, motivational and interpersonal responsiveness in children
with autism during joint engagement episodes. Improvisational music therapy is
an individualized intervention that facilitates moment-by-moment motivational
and interpersonal responses in children with autism. Compared with other
therapeutic interventions utilizing music as a background or contingent
stimulus, improvisational music therapy involves the interactive use of live
music for engaging clients to meet their therapeutic needs. It is gaining
growing recognition as an effective intervention addressing fundamental levels
of spontaneous self-expression, emotional communication and social engagement
for individuals with a wide range of developmental disorders.

Design

This randomized controlled
exploratory study employed a single subject comparison design in two different
conditions (improvisational music therapy versus toy play sessions) and two different
parts of a session (an undirected/child-led part versus a more directed/therapist-led
part) in each condition. The objective was to compare the effects of these two
different media (music versus toys) and to determine how children respond in a musical
context with or without direction, compared with a non-musical context such as
play activities with toys with or without direction.

Participants and Procedure

Participants were children
aged between 3 and 5 who were not previously treated with either music therapy
or play therapy. A total of ten children (all male) completed the clinical
trials. Five children were non-verbal while the other five were verbal with
varying degrees of language skills. Eight children were in preschool special
education, and two were in mainstream preschool programs that included
additional therapeutic supports, such as speech language therapy. The children
were randomly assigned either to have the music therapy sessions first and the
toy play sessions later (group 1), or vice versa (group 2). In order to
differentiate the media used in these two conditions, the therapists in music
therapy were instructed to interact with the child mainly through music,
whereas the therapists in the toy play condition were instructed to engage the
child by any means, but to avoid any musical media, such as singing or rhythmic
playing.

Observed behaviors were
recorded in terms of both their frequency and their duration for two broad
categories. The first category concerned the participant’s emotional and
motivational responsiveness (joy, emotional synchronicity, initiation of
engagement) towards different types of attunement promoted by the therapist in
these two conditions. The second category concerned two different types of
responsiveness towards the therapist’s initiation of interaction (social
invitation and interpersonal demands). Joy referred to an event when the child
either smiled (facial expression duration only), or laughed (facial expression
with vocal sound) during the interaction with the therapist. Emotional
synchronicity referred to an event when the child and the therapist shared a
moment of emotional affect duration (happiness or sadness) while engaged with
each other. Initiation of engagement referred to an event where the child
spontaneously initiated interaction with the therapist, or initiated a change
during ongoing interaction, and then expected the therapist to follow.

Results and Discussion

Improvisational music
therapy produced markedly more and longer events of joy, emotional synchronicity
and initiation of engagement behaviors in the children than toy play sessions.
In response to the therapist’s interpersonal demands, ‘compliant (positive)
responses’ were observed more in music therapy than in toy play sessions, and
‘no responses’ were twice as frequent in toy play
sessions as in music therapy. In the music therapy condition, there were more joy,
emotional synchronicity and initiation of engagement events in the undirected
part than the directed part, suggesting that children were happier, more able
to express their happy emotions and more able to share their affects with the
therapist when leading. These results suggest that musical attunement enhances
musical-emotional communication together with joy and emotional synchronicity,
which results in children’s spontaneous willingness to respond, initiate and
engage further.

According to the authors,
“The temporal structure of music and the specific use of musical attunement in
improvisational music therapy suggests that we can help children with autism
experience and develop affective skills in a social context.” Creating music relates to the child’s
expression, interest and focus of attention may evoke responses from the child
to a therapist creating such relational music for them. Moreover, improvising
music together is an emotionally engaging process. Music can be an attractive
medium, allowing the child his/her own space and the choice of objects, at the
same time engaging the child with different objects of the therapist’s choice.

Of course, this
“exploratory” study has limitations.For
example, the small sample makes any generalizable conclusion premature. The
test power is low and should be considered when interpreting the results.
Likewise, the small sample limits the relevance of subgroup analyses (language,
age, severity) as well as therapists’ effects which would be helpful to
understanding how children with different developmental needs respond to this
type of intervention different therapists.

Conclusion

In conclusion, the results
of this exploratory study found significant evidence supporting the value of
music therapy in promoting social, emotional and motivational development in
children with autism. The findings highlight the importance of social-motivational
aspects of musical interaction between the child and the therapist, the
therapeutic potential of such aspects in improvisational music therapy, and the
relative value of less directed and more child centered approaches for children
with autism. The authors conclude, “Both previous and the current study
indicate that we should use music within the child’s focus of attention,
behavioral cue and interests, whether it is improvised or precomposed. A future
study should perhaps look at the differential effect on response of improvised
and precomposed music with young children with autism.”

Monday, August 10, 2015

The removal of Asperger’s
disorder (Asperger syndrome) as a separate diagnostic category from the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
has been widely publicized. The new DSM-5 category of autism spectrum
disorder (ASD), which subsumes the previous DSM-IV diagnoses of autistic
disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder
not otherwise specified (PDD-NOS), reflects the scientific consensus that
symptoms of the various DSM-IV subgroups represent a single continuum of
impairment that varies in level of severity and need for support.

An important feature of
the DSM-5 criteria for ASD is a change from three symptom domains (triad)
of social impairment, communication deficits and repetitive/restricted
behaviors, interests, or activities to two domains (dyad); social/communication
deficits and fixated and repetitive pattern of behaviors. Several
social/communication criteria were merged to clarify diagnostic requirements
and reflect research indicating that language deficits are neither universal in
ASD, nor should they be considered as a defining feature of the diagnosis. The
criteria also feature dimensions of severity that include current levels of language
and intellectual functioning as well as greater flexibility in the criteria for
age of onset and addition of symptoms not previously included in the DSM-IV such
as sensory interests and aversions.

DSM-IV Criteria in Practice

Problems in applying the DSM-IV
criteria were a key consideration in the decision to delete Asperger’s disorder
as a separate diagnostic entity. Numerous studies indicate that it is difficult
to reliably distinguish between Asperger syndrome, autism, and other disorders
on the spectrum in clinical practice (Attwood, 2006; Macintosh &
Dissanayake, 2006; Leekam, Libby, Wing, Gould & Gillberg, 2000; Mayes &
Calhoun, 2003; Mayes, Calhoun, & Crites, 2001; Miller & Ozonoff, 2000;
Ozonoff, Dawson, & McPartland, 2002; Witwer & Lecavalier, 2008). For
example, children with autism who develop proficient language have very similar
trajectories and later outcomes as children with Asperger disorder (Bennett et
al., 2008; Howlin, 2003; Szatmari et al., 2000) and the two are
indistinguishable by school-age (Macintosh & Dissanayake, 2004),
adolescence (Eisenmajer, Prior, Leekam, Wing, Ong, Gould & Welham 1998;
Ozonoff, South and Miller 2000) and adulthood (Howlin, 2003). Individuals with
Asperger disorder also typically meet the DSM-IV communication criterion of
autism, “marked impairment in the ability to initiate or sustain a conversation
with others,” making it is possible for someone who meets the criteria for
Asperger’s disorder to also meet the criteria for autistic disorder.

Treatment and Outcome

Another important consideration
was response to treatment. Intervention research cannot predict, at the present
time, which particular intervention approach works best with which individual.
Likewise, data is not available on the differential responsiveness of children
with Asperger’s disorder and high-functioning autism to specific interventions
(Carpenter, Soorya, & Halpern, 2009). There are no empirical studies
demonstrating the need for different treatments or different responses to the
same treatment, and in clinical practice the same interventions are typically
offered for both autism and Asperger’s disorder (Wilkinson,
2010). Treatments for impairments in pragmatic (social) language and
social skills are the same for both groups.

Application of DSM-5 Criteria

It’s important to remember
that in the DSM, a mental disorder is conceptualized as a clinically important
collection of behavioral and psychological symptoms that causes an individual
distress, disability or impairment. The objective of the DSM-5 criteria for ASD
is that every individual who has significant “impairment” in
social interaction and communication, and restricted and repetitive behavior or interests should
meet the diagnostic criteria for ASD. Because language impairment/delay is not a necessary
criterion for diagnosis, anyone who demonstrates severe and sustained
impairments in social skills and restricted, repetitive patterns of behavior,
interests, or activities in the presence of generally age-appropriate language
acquisition and cognitive functioning, who might previously have been given a
diagnosis of Asperger’s disorder, now meet the criteria for ASD. Specifiers are used to indicate level of severity and "without accompanying intellectual impairment and language impairment."

The DSM-5 criteria for
ASD have created significant controversy over concerns that it would exclude
many individuals currently diagnosed with Asperger syndrome and PDD-NOS, and
thus make it difficult for them to access services. However, recently published
field trials suggest that the revisions actually increase the reliability of
diagnosis, while identifying the large majority of those who would have been
diagnosed under the DSM-IV-TR. Of the small numbers who were not included, most
received the new diagnosis of “social communication disorder.” Moreover, the
accuracy of non-spectrum classification (specificity) made by DSM-5 was better
than that of DSM-IV, indicating greater effectiveness in distinguishing ASD
from non-spectrum disorders such as language disorders, intellectual
disability, attention-deficit/hyperactivity disorder (ADHD), and anxiety
disorders. It is important to note that all individuals who have a DSM-IV
diagnosis on the autism spectrum, including those with Asperger syndrome and
PDD-NOS, will be able to retain an ASD diagnosis. This means that no one should
“lose” their diagnosis because of the changes in diagnostic criteria. According to DSM-5, individuals with a
well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder, or
PDD-NOS should be given a diagnosis of ASD.
Those who have marked deficits in social communication, but whose
symptoms do not meet the criteria for ASD, should be evaluated for Social
(Pragmatic) Communication Disorder.

Conclusion

In conclusion, the DSM-5
category of autism spectrum disorder (ASD), which subsumes the current
diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified (PDD-NOS), better describes our
current understanding about the clinical presentation and course of the
neurodevelopmental disorders. Conceptualizing autism as a spectrum condition
rather than a categorical diagnostic entity is in keeping with the extant
research suggesting that there is no clear evidence that Asperger’s disorder
and high-functioning autism are different disorders. As Gillberg (2001) notes,
the terms Asperger's syndrome and high-functioning autism are more likely
“synonyms” than labels for different disorders. Lord (2011) also comments that
although there has been much controversy about whether there should be separate
diagnoses, "Most of the research has suggested that Asperger's syndrome
really isn't different from other autism spectrum disorders." "The
take-home message is that there really should be just a general category of
autism spectrum disorder, and then clinicians should be able to describe a
child's severity on these separate dimensions." Unfortunately, many
individuals may have been advised (or assumed) that a diagnosis of Asperger’s
disorder was separate and distinct from autism and that
intervention/treatment, course, and outcome were clinically different for each
disorder. While including Asperger’s Disorder under the DSM-5 category of ASD
will likely continue to require a period of transition and adjustment, this dimensional approach to diagnosis will likely result in more effective
identification, treatment, and research for individuals on the spectrum.

Howlin, P. (2003). Outcome
in high-functioning adults with autism with and without early language delays:
Implications for the differentiation between autism and Asperger syndrome. Journal
of Autism and Developmental Disorders, 33, 3–13.

Monday, July 27, 2015

Alexithymia is
characterized by difficulties in identifying, describing, and processing one's
own feelings, often marked by a lack of understanding of the feelings of
others, and difficulty distinguishing between feelings and the bodily
sensations of emotional arousal. Alexithymia is not a formal clinical diagnosis
and is best conceptualized as a dimensional personality trait that is normally
distributed in the general population (with estimates of 10%) and varies in
severity from person to person. However, there is evidence to suggest that it
is associated with an increased risk for mental health problems. For example,
several studies indicate that even in childhood, alexithymia and difficulties
in the domain of emotion processing are positively related to internalizing
problems such as anxiety and depression.

Research indicates that
alexithymia overlaps with autism spectrum disorder (ASD). Although alexithymia
is not a core feature of autism, recent studies have found varying degrees of
this trait in 50 to 85% of individuals with autism ASD. The alexithymia trait
appears to have the following properties: (a) it is more common in individuals
with ASD than in the general population (b) it is more common in parents of
individuals with ASD than in parents of individuals with another developmental
disabilities, (c) it is stable over time in ASD, and (d) problems in the domain
of emotion awareness are positively related to depression, anxiety, somatic
complaints, worry and rumination. There is also evidence to indicate that the
alexithymia trait might be part of the broader autism phenotype and a
significant component of the emotion processing difficulties observed in ASD. It
is uncertain whether the problem of emotion recognition
commonly attributed to individuals on the autism spectrum is a result of the
disorder itself, or if it is due to the large co-occurrence (comorbidity)
between alexithymia and autism.

Given the apparent
association between alexithymia and autism, it’s especially important to
investigate the relative contribution of this dimensional trait to the
impairment in social functioning experienced by individuals with ASD. An
important question for future research relates to the prevalence of high levels
of alexithymia in ASD compared to neurotypical individuals and how to explain
the high co-occurrence (comorbidity) between alexithymia and ASD. Is
alexithymia a neuroanatomical structural consequence or is the result of a
neurobiological impairment, or is it a distinctive personality trait of
individuals with ASD? Does the level of alexithymia predict symptom severity in
ASD? Although not a diagnostic feature of autism, would alexithymia be a useful
diagnostic marker for ASD? Because alexithymia is associated with increased
risk of mental health problems (i.e., anxiety and depression), should a measure
of alexithymia be included in an assessment battery for ASD? As with most
autism research, there are more questions than answers.

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